Surgical Bleeding
Upcoming SlideShare
Loading in...5
×
 

Surgical Bleeding

on

  • 5,967 views

 

Statistics

Views

Total Views
5,967
Views on SlideShare
5,955
Embed Views
12

Actions

Likes
1
Downloads
133
Comments
0

2 Embeds 12

http://www.slideshare.net 11
http://translate.googleusercontent.com 1

Accessibility

Upload Details

Uploaded via as Microsoft PowerPoint

Usage Rights

© All Rights Reserved

Report content

Flagged as inappropriate Flag as inappropriate
Flag as inappropriate

Select your reason for flagging this presentation as inappropriate.

Cancel
  • Full Name Full Name Comment goes here.
    Are you sure you want to
    Your message goes here
    Processing…
Post Comment
Edit your comment

    Surgical Bleeding Surgical Bleeding Presentation Transcript

    • Surgical Bleeding Presented by Nargess Tavakoli Guilan University of Medical Sciences
    • Excessive Intraoperative or Postoperative Bleeding
    • may be the result of:
      • ineffective local hemostasis
      • complications of blood transfusion
      • a previously undetected hemostatic defect
      • consumptive coagulopathy, and/or fibrinolysis.
    •  
    • Ineffective Local Hemostasis Ineffective Local Hemostasis
      • Excessive bleeding from the field of the procedure
      • without bleeding from other sites
      • e.g. cvp line
      • intravenous line
      • tracheostomy
    • exception
      • operations on the
      • Prostate
      • Pancreas
      • Liver
      • operative trauma =>
      • local plasminogen activation =>
      • increased fibrinolysis on the raw surface
      • EACA: 24-48-hour interruption of plasminogen activation
      • laboratory investigation must be confirmatory
      • number of plt
      • actual plt count: if the smear is equivocal
      • aPTT
      • PT
      • TT
    • complications of blood transfusion
    •  
    • complications of blood transfusion
      • thrombocytopenia due to massive blood transfusion
      • hemolytic transfusion reaction
      • Transfusion purpura
    • thrombocytopenia due to massive blood transfusion
      • massive transfusion
      • a single transfusion greater than 2500 mL
      • 5000 mL transfused over a period of 24 hours.
    • thrombocytopenia due to massive blood transfusion
      • usually not associated with hemostatic failure
      • prophylactic administration of plt: not indicated
    • if evidence of diffuse bleeding:
      • empiric transfusion of 8_10 packs of fresh platelet concentrates
      • no clear association between plt count,BT & the occurrence of profuse bleeding
    • hemolytic transfusion reaction
      • Example:
      • anesthetized patient :
      • diffuse bleeding in an operative field that had previously been dry
      • Pathogenesis:
      • red blood cells lysis=>
      • release of ADP=>
      • diffuse plt aggregation=>
      • the plt clumps are swept out of the circulation
      • Release of procoagulants =>
      • progression of the clotting mechanism =>
      • intravascular defibrination
      • The fibrinolytic mechanism may be triggered.
    • Transfusion purpura
    • Transfusion purpura
      • uncommon
      • donor plt :uncommon Pl A 1 group
      • Recipient makes Ab to the foreign plt Ag
      • foreign plt antigen attach to the recipient's own plt
      • sufficient titer of Ab to destroy recipent’s plt: within 6 or 7 days
      • resultant thrombocytopenia & bleeding may continue for several weeks
      • bleeding follows transfusion by 5 or 6 days:
      • Transfusion purpura as DDx.
    • Management:
      • Platelet transfusions :
      • little help
      • damage from the Ab
      • Corticosteroids:
      • some help
      • self-limited
    • DIC and disseminated fibrinolysis
    • DIC and disseminated fibrinolysis
      • control mechanisms fail to restrain the hemostatic process to the area of tissue damage
    • Caused by:
      • trauma
      • incompatible transfused blood
      • Sepsis
      • necrotic tissue
      • fat emboli
      • retained products of conception
      • toxemia of pregnancy
      • large aneurysms
      • liver diseases
      • distinguish between the two processes or the dominant element : important
      • No single test
      • can confirm or exclude the diagnosis or distinguish between the two disorders
    • strong indications for DIC
      • The combination of
      • Thrombocytopenia
      • plasma protamine test for fibrin monomers:+
      • fibrinogen level : LOW
      • FDP : ELEVATED
      • The euglobulin lysis time
      • detects diffusefibrinolysis
    • Biliary tract surgery in cirrhotic patients & Bleeding
      • Related to:
      • portal hypertension
      • coagulopathy associated with chronic liver disease
      • The tests used to distinguish DIC from fibrinolysis pertain
      • The therapeutic approach
      • IV vasopressin : temporary reduction in portal hypertension
      • EACA to correct the increased fibrinolysis
    • The therapeutic approach
      • IV vasopressin : temporary reduction in portal hypertension
      • EACA to correct the increased fibrinolysis.
    • Intra/Postoperative Bleeding & sepsis
      • Endotoxin-induced thrombocytopenia
      • Defibrination
    • Endotoxin-induced thrombocytopenia
      • Gram Neg. sepsis
      • a labile factor (possibly factor V)
    • Defibrination
      • meningococcemia
      • Clostridium perfringens sepsis
      • staphylococcal sepsis
      • Hemolysis leading to defibrination
      • Evaluation:plt count, INR, aPTT,TT
    • Preoperative Evaluation of Hemostasis
    • Ask the patient 8Qs
      • prolonged bleeding or swelling after biting the lip or tongue?
      • bruises without apparent injury?
      • prolonged bleeding after dental extraction?
      • excessive menstrual bleeding?
      • bleeding problems associated with major and minor operations?
      • medical problems receiving a physician's attention within the past 5 years?
      • medical problems receiving a physician's attention within the past 5 years?
      • medications including aspirin or remedies for headache taken within the past 10 days ?
      • a relative with a bleeding problem?
    • Four levels
      • Based on:
      • History
      • surgical procedure
    • level I
      • History: negative
      • procedure: relatively minor
      • e.g., breast biopsy
      • hernia repair
      • no screening tests are recommended
    • level II
      • history:negative
      • major operation but usually is not attended by significant bleeding
      • platelet count
      • PBS
      • PTT
    • Level III
      • history : suggestive of defective hemostasis
      • procedure :hemostasis may be impaired, e.g., operating using pump oxygenation or cell savers
      • procedures : a large, raw surface is anticipated
      • situations :minimal postoperative bleeding could be injurious(intracranial operations)
    • Level III
      • plt count & bleeding time test : platelet function;
      • aPTT & INR : coagulation
      • the fibrin clot should be incubated to screen for abnormal fibrinolysis
    • Level IV
      • history highly suggestive of a hemostatic defect
      • consult with ahematologist
      • tests prescribed for level III
      • BT test :4 hours after ingestion of 600 mg of aspirin operation is scheduled to take place 10 or more days after this study.
    • Level IV
      • emergency procedure:
      • platelet aggregation tests ADP, collagen, epinephrine, and ristocetin
      • TT : detect any dysfibrinogenemia or a circulating, weak, heparin-like anticoagulant.
      • uremic patients
      • Qualitative platelet abnormality
      • most common deficit
      • best detected by the bleeding time test .
    • Thanks for your attention